ABSTRACT
A new Joint Commission Sentinel Event Alert warns about the frequency of suicide by nonpsychiatric patients in EDs and medical-surgical units. Almost 25% of suicides reported to The Joint Commission (TJC) occurred in nonpsychiatric settings.Some risk factors for these patients include dementia, traumatic brain injury, chronic pain or intense acute pain, poor prognosis or terminal diagnosis, and substance abuse. TJC recommends: * educating staff about suicide risk factors and warning signs that a suicide attempt is imminent. * empowering staff to call a mental health professional if they notice changes in a patient's behavior. * empowering staff to take action, such as placing a patient under constant observation if the patient exhibits suicide warning signs.For more information and recommendations, visit TJC's website at http://www.jointcommission.org .Source: The Joint Commission. A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department. Sentinal Event Alert, November 17, 2010.In a 6-year study at 10 North Carolina hospitals, researchers found scant evidence of widespread improvement in error prevention-despite intensive efforts to improve patient safety triggered by the Institute of Medicine's landmark report, To Err is Human.In more than 2,300 randomly selected admissions, researchers found 588 instances of patient harm, including hospital-acquired infections, surgical errors, and drug dosage mistakes. Most errors were minor, but 50 were life-threatening. Fourteen patients died and 17 suffered permanent injury. About half of the errors were avoidable.Although researchers identified a reduction in preventable harms, the reduction wasn't statistically significant. There was no significant change in the overall rate of harms, which includes both errors and unavoidable mistakes. Researchers call for more efforts to "translate effective safety interventions into routine practice and to monitor health care safety over time."Source:

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